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Soru

Zorluk: KolayReduction of Risk Potential

A practical nurse is caring for a client who had a percutaneous liver biopsy 2 hours ago. The client's heart rate has increased from 80 to 118 beats per minute, and blood pressure has decreased from 122/76 mm Hg to 92/58 mm Hg. Which action should the practical nurse take first?

  1. Notify the registered nurse (RN) immediately.Cevap
  2. B
    Document the vital signs and recheck them in 30 minutes.
  3. C
    Administer the prescribed as-needed pain medication.
  4. D
    Increase the rate of the maintenance intravenous fluids.

Cevap

Notify the registered nurse (RN) immediately.
The correct answer is to notify the RN immediately. A percutaneous liver biopsy involves inserting a needle into a highly vascular organ, putting the client at significant risk for internal bleeding. Tachycardia (increased heart rate) and hypotension (decreased blood pressure) are classic early signs of hemorrhage and hypovolemic shock. Because this is a life-threatening emergency, the practical nurse must escalate the findings immediately to the RN, who will coordinate with the healthcare provider for further interventions.

Adım Adım Çözüm

1
Analyze the client's current vital signs compared to the baseline.
The heart rate has significantly increased (tachycardia) and the blood pressure has decreased (hypotension).
Identifying abnormal trends in vital signs helps recognize physiological deterioration.
2
Correlate the vital sign changes with the recent procedure.
A liver biopsy carries a high risk of hemorrhage. The vital sign changes strongly suggest active internal bleeding.
Understanding procedure-specific risks is essential for anticipating and identifying life-threatening complications.
3
Determine the priority action based on the practical nurse's scope of practice.
The client is experiencing a life-threatening complication that must be immediately reported to the RN for collaborative emergency management.
Prompt escalation ensures the client receives timely medical interventions.

Anahtar Kavram

Early recognition of shock and appropriate escalation within the practical nursing scope of practice.
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Konular

Reduction of Risk Potential

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